1. ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry ® Illinois Medical Bill Reviewer Training Program Unit 1: Professional Services Module 1: Evaluation and Management

2. 2 Illinois Regulation Training – E & M Overview Hi! In this module, you will learn about evaluation and management services, how they are classified, and the difference between new and established patients. Then, you will learn about emergency department codes, the difference between consultations and referrals, and how same day E & M services are reimbursed. Lets start by discussing how E & M services are classified... Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services

3. 3 Illinois Regulation Training – E & M Evaluation and Management Guidelines Evaluation and Management services focus on the initial understanding and diagnosis of an illness or injury, as well as facilitating the necessary treatment to cure the illness or injury. The E & M section ranges from 99201- 99499.

4. 4 Illinois Regulation Training – E & M Classification of Services Evaluation and management services are classified differently depending on the type of service as well as where the service is rendered. Evaluation and Management can be classified as: Office visits Hospital visits Consultations Evaluation and management services can also be classified by intensity. Lets take a look…

5. 5 Illinois Regulation Training – E & M Classification of Services Evaluation and Management services that have different intensities are considered different levels of service. The following levels of service can be assigned: Comprehensive Detailed Expanded Problem Focused Problem Focused Increasing Intensity

6. 6 Illinois Regulation Training – E & M Classification of Services Different levels of services are determined primarily by three key components. The following levels of service can be assigned: Comprehensive Detailed Expanded Problem Focused Problem Focused Levels of services are determined primarily by: History Examination Complexity of Medical Decision-making Increasing Intensity Each component of an evaluation is assigned a level of service.

7. 7 Illinois Regulation Training – E & M New vs. Established Patients Lets take a look… Now that you understand how evaluation and management services are classified, we can discuss how patients are classified.

8. 8 Illinois Regulation Training – E & M New vs. Established Patients There are two types of patients within evaluation and management office visits: New Patients Established Patients Lets take a look…

9. 9 Illinois Regulation Training – E & M New Patients A new patient is one who is new to the physician, or an established patient with a new injury or condition. New Patients

10. 10 Illinois Regulation Training – E & M New Patients Seen By Multiple Physicians If a patient sees different specialists within a multi- specialty medical group, each specialist is entitled to use a new patient code on the initial visit. Only one physician per specialty may charge as a new patient visit for the same injury or condition. If a different physician within the same specialty is on call and sees a patient, the visit is billed as it would have been by the regular treating physician.

11. 11 Illinois Regulation Training – E & M Established Patients An established patient is one who has been seen for the same injury or illness. Established Patients

12. 12 Illinois Regulation Training – E & M Established Patients Established patients may return for a follow-up visit regarding the status of the initial illness or injury. Follow-up visits by established patients are automated in the bill review system. 1. If a second initial visit is billed, the bill review system suspends the bill and prompts the processor to evaluate whether the same provider is billing for a second initial visit. 2. If a second initial visit is billed, the processor should substitute with a comparable subsequent visit code.

13. 13 Illinois Regulation Training – E & M Hospital Visits Now that you are familiar with the basics of E & M services, lets discuss how hospital visits are reimbursed. Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services Hospital Visits

14. 14 Illinois Regulation Training – E & M Hospital Visits Similar to office visits, there are two categories of patients within hospital visits: Initial Visits Subsequent Visits Lets take a look…

15. 15 Illinois Regulation Training – E & M Initial Hospital Visits The other services are not to be billed separately. If a patient is admitted to a hospital in the course of being seen elsewhere, including... Emergency department Observation Physicians office Nursing facility... all E/M services provided for that condition are included in the initial hospital visit.

16. 16 Illinois Regulation Training – E & M Example: Suppose Mr. Johnson is seen by Dr. Gade in the office for a possible back injury. The physician sends him to the hospital for x-rays, then sees Mr. Johnson in the ER. Mr. Johnson is admitted to the hospital for a vertebral fracture. Dr. Gade can charge for an initial hospital visit, but the office visit and the ER visit are included. The work and time involved in the first two encounters are considered as part of the initial visit service level. Initial Hospital Visits

17. 17 Illinois Regulation Training – E & M Initial Hospital Visits In some instances, physicians admit patients to the hospital by phone. If a physician admits a patient by phone, they report the initial hospital visit code on the day they actually see the patient.

18. 18 Illinois Regulation Training – E & M Subsequent Hospital Visits Subsequent visits occur when the physician visits a hospitalized patient on subsequent days. If the same physician, or a physician from the same specialty group visits the patient, the visit should be billed as a subsequent visit. Hi Mr. Jones, you are looking better today. Reimbursement for subsequent visits differs depending on who provides the subsequent visit.

19. 19 Illinois Regulation Training – E & M Subsequent Hospital Visits However, if a physician from a different specialty group visits the patient, the service may be billed with initial inpatient consultation codes or subsequent hospital care codes. Dr. Meyer says that your symptoms are improving. This means that only one initial hospital visit can be billed per patient.

20. 20 Illinois Regulation Training – E & M Observation Services Prior to being admitted to the hospital, a patient is occasionally placed under observation. In these cases, observation codes are used. There are two types of observation services: Initial Discharge Lets take a look…

21. 21 Illinois Regulation Training – E & M Initial Observation Codes Like other evaluation and management services, observation codes are not to be charged for post-operative care in connection with a surgical service. Initial observation services are reported per day. It is expected that a decision will be made within a day to send the patient home or admit him to the hospital.

22. 22 Illinois Regulation Training – E & M Example Initial Observation Codes If the patient is admitted to the hospital, the observation charges are rolled into the initial hospital visit. But, if the patient is admitted to observation and discharged on the same day, the only code used would be an initial admit code from 99218- 99220.

23. 23 Illinois Regulation Training – E & M Discharge Observation Services Discharge observation services are only reported when the patient is discharged from the hospital on a different day than they were admitted. Discharge observation services are indicated by CPT 99217: Observation care discharge.

24. 24 Illinois Regulation Training – E & M Prolonged Service Code Characteristics: Prolonged Service Codes Prolonged Service Codes are codes used when a physician provides a service beyond the typical service time for a specific E & M code. The service provided and the length of time required must be identified and documented.

25. 25 Illinois Regulation Training – E & M Prolonged Service Codes There are two types of prolonged service codes: Direct (Face to Face) Contact Without Direct Contact Lets take a look…

26. 26 Illinois Regulation Training – E & M Direct (Face to Face) Contact Outpatient setting: CPT 99354: 31 to 74 minutes. CPT 99355: Each additional 30 minute increment. Inpatient setting: CPT 99356: 31 to 74 minutes. CPT 99357: Each additional 30 minute increment. Direct (Face to Face) Contact

27. 27 Illinois Regulation Training – E & M Without Direct Contact CPT 99358: used to report the first hour spent (30-74 minutes) reviewing records and tests, or communicating with other medical professionals, during or following direct contact with a patient.

28. 28 Illinois Regulation Training – E & M Emergency Department Emergency department codes are reimbursed slightly differently than other E & M services. Lets take a look... Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services Emergency Department Services

29. 29 Illinois Regulation Training – E & M Emergency Department Services Emergency Department Services: services rendered in a 24- hour hospital-based facility designed to accommodate immediate medical care to patients requiring unscheduled treatments. There is no distinction between new or established patients in the emergency department. Emergency department (ED) codes are only to be billed for services in the ED. Services provided elsewhere, including an urgent care center, are not eligible for emergency room coding. In addition, for any single ED patient visit, only one physician can report an ED E/M code. If two physicians see the patient, one may code for an ED visit and the other for another appropriate visit.

30. 30 Illinois Regulation Training – E & M Emergency Department Services Like other types of evaluation and management services, emergency department visits tend to vary with intensity. Because of the extensive variability, time is not a descriptive component of an emergency department visit. Emergency department visits vary with: The number of patient encounters Time waiting for test results Medication Patient observation Care of other patients

31. 31 Illinois Regulation Training – E & M Emergency Department Codes Instead, emergency department visits are coded by key components and the nature of the presenting problem. Lets take a look… Emergency department codes vary by: The severity of the injury or illness. The extent of treatment. As a result, like evaluation and management codes, emergency department codes also vary.

32. 32 Illinois Regulation Training – E & M Example 2Example 1 CPT 99285 CPT 99281 Emergency Department Codes Corresponds to minor injuries or illnesses that require straightforward examination and treatment, such as: Emergency department visit for the treatment of poison ivy. Emergency department visit for the diagnosis and wrap of a sprained ankle. Corresponds to severe injuries or illnesses that pose an immediate threat to the patients life, such as: Emergency department visit for internal bleeding. Emergency department visit for severe chest pain.

33. 33 Illinois Regulation Training – E & M Critical Care Services If services provided in the emergency department are of a critical nature, and meet certain criteria, a critical service code may be billed in addition to the appropriate evaluation and management code(s). Critical care services may be billed for direct delivery of care in the ED to a critically ill or injured patient. Critical care service criteria: Total time delivering critical care services must be greater than 30 minutes. Physician must be in constant attendance, or involved in treatment directly. Separate documentation of critical care services must be included. Separate documentation is important because unlike other ED services, critical care services are paid by time rather than key components and the presenting problem.

34. 34 Illinois Regulation Training – E & M Consultations and Referrals Lets take a look… Evaluation and Management services can be billed differently if the physician provides advice regarding a diagnosis, or facilitates the transfer of a patient to a different physician.

35. 35 Illinois Regulation Training – E & M Consultations and Referrals Evaluation and Management services are distinguished by: ConsultationsReferrals Lets take a look…

36. 36 Illinois Regulation Training – E & M Consultations A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Consultations The physician may order diagnostic tests in order to form an opinion regarding the patients diagnosis.

37. 37 Illinois Regulation Training – E & M Consultations In order for a visit to be classified as a consultation, the three ROs must be met. pinion equest for an pinion endering an pinion eport of an

38. 38 Illinois Regulation Training – E & M Referrals A referral constitutes the transfer of the total or specific care of a patient from one physician to another. Referrals do not constitute a consultation. Referrals

39. 39 Illinois Regulation Training – E & M Referrals If the referring physician writes eval and treat they are, in essence, referring the patient to the other physician and not asking for an opinion. This is true even if the specialist sends a report to the referring physician, which is considered only a professional courtesy.

40. 40 Illinois Regulation Training – E & M Where might you find documentation of the referral? Referrals Sometimes, a physician refers a patient to another physician without a written or verbal request for a consultation. The patient referral should be documented in the patients records. In these instances, the referral should be reported using office codes, outpatient codes (99201-99215), or subsequent hospital care codes.

41. 41 Illinois Regulation Training – E & M Same Day E & M Services Lets take a look… Occasionally, the same patient receives multiple E & M services on the same day...

42. 42 Illinois Regulation Training – E & M Same Day E & M Services There are instances when a provider bills for an E&M twice on the same day. Lets take a look… Before denying the charge as a duplicate, you must check the providers documentation carefully. There are instances when the charges are allowable.

43. 43 Illinois Regulation Training – E & M Same Day E & M Visits I am glad he came in again…we should be able to repair the damage… You should be fine…come back in if you continue to experience symptoms… Subsequent E & M visits are allowable if: Charges are for different specialists in the same group. The patient experienced difficulties or complications that required a second trip to the office or emergency room.

44. 44 Illinois Regulation Training – E & M E&M Coding Accuracy Providers are relied upon to code their visits accurately and fairly. However, during the review of a bill, any office visit on that bill may be evaluated for correctness of the assigned type and level of E/M service. Also, utilization review departments working on behalf of the payors and 3 rd party administrators will look for patterns of abuse in provider coding.

45. 45 Illinois Regulation Training – E & M Summary How E & M services are classified and who can bill them. The difference between new and established patients. Emergency department service codes. Same day E & M services: What is allowable? The difference between consultations and referrals. Patients seen by multiple physicians.